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Abstract

Background

Given the epidemic of childhood obesity, it is crucial to assess food and beverage
intake trends. Beverages can provide a large number of calories and since consumption
patterns seem to develop at a young age we examined beverage consumption trends over
three decades. The objective of this study was to assess the beverage (milk, fruit
juice, fruit drinks, tea, soy beverages, and soft drinks) consumption trends in children
<1-5 years of age.

Methods

Data from individuals ages <1-5 years participating in the National Health and Nutrition
Examination Survey (NHANES) from 1976–1980, 1988–1994 and 2001–2006 were used to assess
beverage consumption and associated calorie and nutrient intakes.

Results

During the NHANES 1976–1980 and 1988–1994 periods, approximately 84–85% of children
were consuming milk, whereas only 77% were consuming milk during NHANES 2001–2006.
Flavored milk intake was relatively low, but increased to 14% during the last decade
(p < 0.001). Fruit juice consumption increased dramatically during NHANES 2001–2006
to more than 50% of the population compared to about 30% in the older surveys (p <
0.001). No significant changes were observed in fruit drink intake across all three
decades with 35-37% of this population consuming fruit drinks. At least 30% of children
consumed soft drinks. Milk was the largest beverage calorie contributor in all three
decades surveyed and was the primary contributor of calcium (52-62%), phosphorus (37-42%),
magnesium (27-28%), and potassium (32-37%). Fruit juice and fruit drinks each provided
8-10% of calories with soft drinks providing 5-6% of calories. Fruit juice was an
important provider of potassium (16-19%) and magnesium (11%). Fruit drinks provided
less than 5% of nutrients examined and soft drinks provided very little of the nutrients
evaluated.

Conclusions

Given concerns about childhood obesity and the need to meet nutrition requirements,
it is prudent that parents, educators and child caretakers replace some of the nutrient
poor beverages young children are currently consuming with more nutrient dense sources
like low-fat and fat-free milk.

Keywords:

Introduction

A child’s first 5 years of life is characterized by rapid growth and development and
is the period during which food preferences and behaviors develop that often serve
as the foundational basis for future eating habits [1,2]. Beverage consumption patterns developed during the early years can have lasting
implications throughout childhood and adolescence and into adult years. The American
Academy of Pediatrics (AAP) provides recommendations for the introduction of beverages
to children’s diets. They discourage fruit juice intake before the infant is at least
4–6 months of age and fruit drinks, sports drinks and energy drinks are generally
discouraged all together [3-5]. The introduction of cow’s milk is recommended after 1 year of age and low-fat and
fat-free varieties are encouraged once children turn 2 years old [3]. The 2010 Dietary Guidelines for Americans acknowledge the important link between
childhood and adulthood beverage consumption by reinforcing the important habit of
drinking milk during childhood because “those who consume milk at an early age are
more likely to do so as adults” [6].

In the nationwide sample of infants and toddlers aged 4–24 months who participated
in the Feeding Infants and Toddlers Study, beverages provided 36% of the total daily
energy [7]. According to 2005–2006 National Health and Nutrition Examination Survey (NHANES)
data, total beverage intake among children ages 2–6 years accounts for an average
of 367 kcal/day [8]. Although milk intake accounted for the greatest amount of fluids consumed in this
young age group (331 ml/day, on average), sodas and fruit drinks provided 206 ml of
average daily fluids and by the time children were 7 years of age and older, sodas
accounted for the most fluid intake, aside from water, while milk intake continued
to decline [8]. The type of beverages consumed can have a significant impact on diet quality and
nutrient adequacy.

Lower milk intake makes it more difficult for young children to meet daily milk and
milk product group and nutrient intake recommendations, and it could have negative
impacts on development since milk and the nutrients it provides are associated with
growth and bone health in preschool children [9,10]. Health professionals are concerned that high calorie, high sugar, nutrient poor
beverages like soft drinks and fruit-flavored drinks displace nutrient rich beverages
such as milk [3]. Sugar-sweetened beverage consumption, primarily referring to carbonated beverages
and fruit drinks, begins during the preschool years and generally increases with age
[11-13]. The consumption of milk by preschoolers has been positively correlated with diet
quality and meeting nutrient recommendations, including vitamin A, folate, vitamin
B12, calcium, and magnesium, whereas sugar-sweetened beverage consumption, including
soda and fruit drinks, by young children has been linked to reduced milk intake and
negatively correlated with achieving intakes of vitamin A, vitamin C, and calcium
[14-16].

Research indicates a link between beverage consumption and body weight as well. Childhood
overweight and obesity has increased at alarming rates in the United States. Even
among children aged 2–5 years of age, obesity defined as body mass index (BMI) greater
than the 95th percentile for age, increased from 5 to 10.4% between 1976–1980 and
2007–2008 [17]. There is evidence that a higher intake of sugar-sweetened beverages, such as soda,
is associated with increased energy intake [18] and body weight and/or adiposity in children [6,18]. Several studies have observed this phenomenon in preschool children [12,19,20].

In light of the importance of beverage consumption to diet quality and obesity among
preschoolers, the purpose of this study was to identify beverage trends in young children
over the past three decades. Particular emphasis was placed on evaluating the role
of milk and its possible displacement with the rising consumption of empty calorie
beverages at this early age.

Methods

Our analysis utilized beverage intake data available from NHANES 1976–1980, 1988–1994,
and 2000–2006 for children less than 1 year of age to 5 years of age. NHANES is an
ongoing cross-sectional nationally representative health and nutrition examination
survey of a stratified, multistage probability sample of the civilian, non-institutionalized
U.S. population [21]. Beverage consumption data was based on 24-hour dietary recalls collected in each
NHANES cycle in which proxy respondents reported on all foods and beverages consumed
by the children in a 24-hour period. While multiple days of recall were obtained in
some NHANES surveys, only one day of recall was used for each subject to allow comparison
over time. Participants whose records were incomplete, unreliable, or were being breastfed
were excluded. Data from NHANES 1976–1980 included only children 6 months and older,
whereas the more recent NHANES included children from birth.

Beverage categories were identified as: milk [total as well as white, flavored (sugar-sweetened),
whole, 2%, 1%, and fat-free separately], 100% fruit juice, fruit drinks, soft drinks,
tea and soy beverages. White milk included all non-flavored fluid milk consumed as
beverages as well as milk consumed with other foods such as cereal and macaroni and
cheese. Flavored milk was defined as flavored fluid milk purchased as such (i.e.,
chocolate, strawberry) or milk prepared by the addition of flavored syrups or powder.
Fruit drinks were beverages with less than 100% juice; most contained added sugars.
Soft drinks included both “regular” and “diet” sodas. The percentage of the population
that consumed each beverage category as well as the amounts consumed by those children
was determined by age. The mean intake and percent of total intake of calories, total
fat, saturated fat, protein, calcium, phosphorus, magnesium (for NHANES 1988–1994
and 2001–2006 only), and potassium were determined for each beverage category using
the respective nutrient content information from each NHANES study period. NHANES
1976–1980 did not measure magnesium intake.

All analyses of percentages and/or means with standard errors were conducted using
SAS version 9.2/SUDAAN version 10.0 (SAS Institute, Cary, NC/RTI, Research Triangle
Park, NC) to adjust for the complex sampling design of each NHANES survey. Pair-wise
comparisons between NHANES 1976–1980 and NHANES 1988–1994, 10–14% NHANES 1988–1994
and NHANES 2001–2006 and NHANES 1976–1980 and NHANES 2001–2006 were performed on mean
percents and means using z scores to identify significant differences.

Results

A total sample of 3,998 children <1–5 years of age was utilized from NHANES 1976–1980,
6,871 from NHANES 1988–1994 and 4,430 from NHANES 2001–2006.

Beverage choice (Percentage use)

Across all three decades, milk was the beverage consumed by most young children (Figure
1). There was a significant decrease (p < 0.001) in milk consumption in the most recent
NHANES surveys compared to the previous surveys. During the NHANES 1976–1980 and 1988–1994
periods, approximately 84–85% of children in this age group were consuming milk, whereas
only 77% were consuming milk during NHANES 2001–2006. Flavored milk intake was relatively
low during NHANES 1976-1980 and NHANES 1988-1994, but increased to 14% during the
last decade (p < 0.001). Fruit juice consumption increased dramatically in this age
group during NHANES 2001–2006 to more than 50% of the population compared to about
30% in the older surveys (p < 0.001). No significant changes were observed in fruit
drink intake across all three decades. On average, 35-37% of this population consumed
fruit drinks. In the case of soft drinks, at least 30% of children consumed this drink
on any given day over the past 30 years. During the NHANES 1988–1994 period, there
was a significant increase to 36% (p < 0.001) which leveled back to 30% in NHANES
2001–2006. Percent of children consuming tea significantly decreased from 10–14% from
previous decades to 7% during NHANES 2001–2006. Consumption of soy beverages were
not recorded in the earlier surveys and intake was less than 1% in NHANES 2001–2006.
In the remaining analyses, tea and soy beverages were excluded because less than 10%
of young children consumed these beverages.

Figure 1.Percentage of children <1–5 years of age consuming different beverages during NHANES
1976-1980, NHANES 1988–1994, and NHANES 2001–2006. NHANES – National Health and Nutrition Examination Survey. Columns with different
letters within beverage category are significantly different (p < 0.01).

Age differences in beverage trends across decades were assessed in relation to total
milk, flavored milk, fruit juice, fruit drink, and soft drinks consumption (Table
1). Among children less than 1 year old, there was an almost 11% increase in milk consumption
in NHANES 2001–2006 compared to NHANES 1988–1994. From the age of 1–5 years, the proportion
of children that consumed milk was similar for the earlier two decades, whereas during
NHANES 2001–2006 there was a tendency for fewer children to consume milk after the
age of 3 years. For children 1–3 and 5 years, there was a significant increase (p < 0.05)
in the percent of children who were consuming milk during NHANES 1988–1994 compared
to NHANES 1976–1980 for nearly all ages. The trend was reversed for NHANES 1988–1994
versus NHANES 2001–2006, where fewer 1, 3 and 5 year olds were consuming milk. Age-related
patterns for flavored milk consumption did not differ for the earlier two surveys
but showed a significant increase (p < 0.05) ranging from about 1% to 17%, depending
on age, during NHANES 2001–2006 compared to NHANES 1988–1994.

Table 1.Percent of children<1–5 years that consumed each beverage in NHANES 1976–1980, NHANES 1988–1994, and NHANES 2001–2006, categorized by age

There was a small, but significant decline (p < 0.05) in the percent of 3–5 year olds
who consumed fruit juice during NHANES 1988–1994 compared to NHANES 1976–1980. In
contrast, there was a significant increase (p < 0.05) in the percent of all children
from 1–5 years of age who consumed fruit juice in NHANES 2001–2006. There was a 22-30
percentage unit increase in fruit juice consumption in children 1 year and older.
Fruit drink intake on the other hand, was not significantly different between the
three decades with the exception of an increase in those less than 1 year of age.
It was particularly evident in NHANES 1988–1994 and NHANES 2001–2006 that a greater
percent of children consume soft drinks with increasing age. For example, in the most
recent survey, approximately 19% consume soft drinks at 1 year of age, 29% at 2 years,
38% at 3 years, 41% at 4 years, and 45% at 5 years. Between NHANES 1976–1980 and NHANES
1988–1994, no clear age differences were present with the exception that there was
an 11 percentage unit increase (p < 0.001) in soft drinks consumption among 5 year
olds in NHANES 1988–1994. Similarly, no significant age differences were found when
NHANES 1988–1994 and NHANES 2001–2006 were compared, except for an increase (p < 0.05)
in children less than 1 year and a significant decrease in 2 year olds (p < 0.05).

Beverage amounts

Overall for the group, there was a small decrease (p < 0.05) in the amount of milk
consumed between NHANES 1976–1980 and NHANES 1988–1994 and an increase (p < 0.001)
between NHANES 1988–1994 and NHANES 2001–2006 (Table 2). Among 1 year olds there was a small increase (p < 0.05) in the mean amount consumed
between NHANES 1976–1980 and NHANES 1988–1994, no significant change in 2 and 3 year
olds, and a small to moderate decline in 4 (p < 0.05) and 5 (p < 0.001) year olds.
In contrast there was a significant increase in the quantity of milk drank by <1–5
year olds when NHANES 2001–2006 was compared to NHANES 1988–1994. Milk consumption
increased from 17.3 to 20.3 fl oz (p < 0.001) in 1 year olds, 13.1 to 16.6 fl oz (p < 0.001)
in 2 year olds, 13.3 to 14.9 fl oz (p < 0.05) in 3 year olds, and 13.0 to 15.0 fl
oz (p < 0.05) in 5 year olds. No significant changes were observed for 4 year olds.
In the most recent survey, 2 and 3 year olds were consuming about 2 cups of milk a
day and 4 and 5 year olds were consuming a little less than 2 cups a day.

Table 2.Average amount of each beverage consumed by children<1–5 years during NHANES 1976–1980, NHANES 1988–1994, and NHANES 2001-2006

Fruit juice consumption increased (p < 0.001) in NHANES 1988–1994 compared to NHANES
1976–1980 and then remained stable through NHANES 2001–2006 for the entire sample.
Children 1–3 years of age consumed significantly more fruit juice in NHANES 1988–1994
than in NHANES 1976–1980. Among 1, 2, and 3 year olds, mean fruit juice intake increased
from 6.6 to 9.3 fl oz (p < 0.05), 8.3 to 11.1 fl oz (p < 0.001), and 7.5 to 10.6 fl
oz (p < 0.05), respectively. Changes were not significantly different for 4 and 5
year olds. The change in amounts consumed from NHANES 1988–1994 to 2001–2006 were
not significantly different for any of the ages tested. During the NHANES 2001–2006
period, children less than 1 year were consuming 5.4 fl oz, children 1–2 years were
consuming about 11 fl oz, children 3 years were consuming 12 fl oz, and children 4–5
years were consuming about 10 fl oz on a daily basis.

The amount of fruit drink ingested did not change significantly for the entire group
during the first two decades, but significantly increased (p < 0.05) during the most
recent one. None of the age groups demonstrated significant changes in the amount
of fruit drink consumed between NHANES 1976–1980 and NHANES 1988–1994. Comparison
of NHANES 1988–1994 to NHANES 2001–2006 indicated significant increases from 9.0 to
12.3 fl oz (p < 0.05) and 10.0 to 12.8 fl oz (p < 0.05) for 1 and 2 year olds, respectively.
No changes between these surveys were observed for 3–5 year olds. The NHANES 2001–2006
survey found that children less than 1 year consumed 8.8 fl oz of fruit drink, and
children 1–5 years consumed about 10–13 fl oz/ day.

Analysis of the group as a whole revealed a small increase (p < 0.05) in the amount
of soft drinks consumed between NHANES 1976–1980 and NHANES 1988–1994 as there were
trends towards an increase among 3 and 5 years olds. No significant changes in the
amounts of soft drinks consumed were noted between NHANES 1988–1994 and NHANES 2001–2006.
During the most recent NHANES analysis, children less than 1 year, 1 year, 2 years,
3 years, 4 years, and 5 years consumed 1.8, 5.4, 6.2, 7.6, 8.8 and 9.8 fl oz, respectively
(p for trend < 0.0001). Increasing age was associated with increased amounts of soft
drinks consumed.

Beverage calorie and nutrient contributions

Among the four main beverages consumed by children <1–5 years, milk was the largest
daily beverage calorie contributor in all three decades surveyed, although there was
a significant reduction in the last two surveys compared to NHANES 1976–1980 (Table
3). These calorie contributions include milk used on cereal or in food mixtures too.
Milk was the primary contributor for all the macronutrients (Table 3) as well as calcium, phosphorus, magnesium, and potassium (Table 4). About 52%, 55%, and 62% of the daily calcium intake were provided by milk in NHANES
2001–2006, NHANES 1988–1994, and NHANES 1976–1980, respectively. The reduced calcium
intake from milk in the more recent surveys is consistent with reduced milk calories.
Phosphorus intake from milk ranged from 37-42% across the three decades. Magnesium
intake from milk was in the range of 27-28% in the last two surveys. Potassium intake
from milk ranged from 31-37%.

Table 3.Energy and macronutrient intake contributed by milk, fruit juice, fruit drink, and soft drinks in the diets of children<1–5 years participating in NHANES 1976–1980, NHANES 1988–1994, and NHANES 2001-2006

Percent daily caloric contribution of fruit juice and fruit drink was similar across
all three surveys, in the range of 8-11%. (Table 3) Fruit juice was an important provider (16-19%) of potassium in the three surveys
and magnesium (11%) in the most recent survey (Table 4). Fruit drinks provided 5% or less of the daily intake of calcium, phosphorus, magnesium,
or potassium in all three surveys (Table 4). The caloric contribution of soft drinks in the range of 5-6% did not significantly
differ among the three surveys (Table 3). Soft drinks provided very little of the nutrients evaluated (Table 4). The combined calorie contribution from fruit juice, fruit drinks and soft drinks
over this thirty year period has increased, but given the parallel rise in total calorie
intake the proportion from these beverages has remained relatively consistent at about
a quarter of total daily calorie intake (1976–1980: 324 kcals, 23% of total kcal intake;
1988–1994: 358 kcals, 25% of total kcal intake; 2001–2006: 384 kcals, 25% of total
kcal intake; data not shown).

Use of different types of milks (Figures 2 and 3) and eating occasion (data not shown) for milk were evaluated in NHANES 1988–94 and
NHANES 2001–2006. In both surveys, whole milk was the predominant milk introduced
at less than 1 year of age and consumed at 1 year of age. Whole milk intake declined
with increasing age in NHANES 2001–2006 compared to NHANES 1988–1994. Two percent
or reduced-fat milk was consumed in almost equivalent amounts by age 5 in the most
recent survey. One-percent milk and skim milk were consumed in very low amounts for
all the years surveyed. Breakfast was the eating occasion where milk was most consumed
in both NHANES 1988–1994 and NHANES 2001–2006. Snack time was the next meal occasion
in which milk was consumed in both surveys. Slightly less milk was consumed at lunch
or dinner than at other meal times. In the context of total dairy intake, relatively
small amounts of milk are consumed during meal occasions.

Figure 2.Servings of milk and type of milk consumed by children <1–5 years of age in NHANES
1988–1994. NHANES – National Health and Nutrition Examination Survey. Cup equivalents represent
8 oz. units.

Figure 3.Servings of milk and type of milk consumed by children <1–5 years of age in NHANES
2001–2006. NHANES – National Health and Nutrition Examination Survey. Cup equivalents represent
8 oz. units.

Discussion

The 2005 Dietary Guidelines for Americans indicated that the nutrients of concern
for children were vitamin E, calcium, magnesium, potassium, and dietary fiber [22]. Beverages are a potential source of calcium, magnesium, and potassium, hence these
nutrients were evaluated in our study, along with phosphorus, a non-fortified nutrient
provided by milk. After our analysis was completed, the 2010 Dietary Guidelines for
Americans were released, which noted vitamin D, calcium, potassium, and dietary fiber
were nutrients of concern for children above the age of 2 [6]. Milk is the primary source of vitamin D in children’s diets, but it was not possible
to evaluate vitamin D trends because vitamin D intake was not assessed in NHANES prior
to 2002.

Milk has been and still is the beverage consumed by most preschool children. However,
there was a trend towards fewer children consuming milk in the last decade as evidence
by this data and previous research [13]. Only 77% of children <1–5 years consumed milk of any type during NHANES 2001–2006
compared to 84-85% in NHANES 1988–1994 and NHANES 1976–1980. To ensure optimal growth
and health, the 2010 Dietary Guidelines for Americans recommends children aged 2–3
years drink 2 cups (16 oz) and children aged 4–8 years drink 2 Â½ cups (20 fl oz)
of fat-free or low-fat milk or equivalent dairy servings a day [6]. On average 2–3 year olds in NHANES 2001–2006 consumed the recommended amount of
milk daily. However, children 4 and 5 years of age were consuming 14–15 fl oz/day;
to meet the Dietary Guidelines, recommendation through fluid milk intake alone, 20
fl oz/day would need to be consumed for this age group. Data from Krebs-Smith, et
al. indicate about one out of four young children 2–8 years old do not meet milk group
recommendations [23]. Although the Dietary Guidelines recommend everyone 2 years of age or older consume
low-fat (i.e., 1%) or fat-free milk; the majority of milk currently consumed by 2–5
year olds was whole or 2% milk. Several studies have shown potential health benefits
of starting consumption of low-fat/fat-free milk early in life [24,25] and reduced-fat milk would be appropriate for overweight or obese children between
12 months and 2 years of age or those with a family history of obesity, dyslipidemia,
or cardiovascular disease [26]. Milk consumption has been reported to increase the likelihood of achieving the recommended
intake of calcium by 37% and increase intakes of vitamin A, folate, vitamin B12, and
magnesium in 2–5 year olds participating in CSFII 1994–96 [14]. This study found that in addition to calcium and magnesium, milk is a major contributor
to the daily intake of phosphorus and potassium in young children. Research has shown
young children who drink flavored milk have comparable or higher intakes of many of
these nutrients compared to those who exclusively drink plain milk, in part because
flavored milk consumers have higher total milk intakes [27].

Over 50% of children 1–5 years consumed fruit juice in NHANES 2001–2006, representing
an increase of 23% from the previous decade. Wang et al. [13] found a non-significant increase from 41% to 46% from NHANES 1988–1994 to NHANES
1999–2004 in their study of children 2–5 years of age. Fruit juice was an important
source of potassium and magnesium in the diets of these children and has been positively
linked to achieving recommended intakes of vitamin C and folate in 2–5 year old children
in previous research [14]. Mean daily fruit juice consumption in 2001–2006 was 5.4 fl oz/day for children less
than 1 year and 10–12 fl oz/day for children 1–5 years. For the entire group, mean
intake was 10.3 fl oz/day in NHANES 2001–2006 compared to 9.5 and 7.4 fl oz/day in
NHANES 1988–1994 and NHANES 1976–1980, respectively. Consistent with our findings,
Wang et al. [13] observed a significant increase from 9.9 fl oz/day in NHANES 1988–1994 to 11.1 fl
oz/day in NHANES 1999–2004 in their preschool sample. This is higher than the fruit
juice amount recommended by the AAP, American Heart Association, and Dietary Guidelines
(4–6 fl oz/day), and some children were introduced to fruit juice or drinks before
the recommended 6 months of age [5,6,28].

In the last three decades, at least 35% of young children consumed fruit drinks, which
is similar to the percentage reported by other studies [14,20]. The data indicate a significant increase in the amount of fruit drinks consumed
in the last decade, particularly in children 1 and 2 years of age. Children less than
1 year consumed 8.8 fl oz/day and children 1–5 years consumed 10–13 fl oz/day in this
analysis of NHANES 2001–2006, which was higher than estimates in CSFII 1994–1996,
1998 (4 fl oz/day) for children 6 months to 6 years [28] and 8 fl oz/day in CSFII 1994–1996 for children 2–5 years. The contribution of calcium,
phosphorus, magnesium, and potassium from fruit drinks was negligible. Generally,
the amount of fruit drinks consumed was greater than fruit juice for children of all
ages analyzed, yet the caloric contribution of fruit drink and fruit juice to these
children’s diets was similar. Across all three decades, fruit drinks provided considerably
more calories in the diets of preschool children than soft drinks. Although fruit
drinks were not a source of the nutrients we measured, many fruit drinks are fortified
with vitamin C which was positively associated with achieving recommended intakes
of vitamin C in the study by Ballew et al. [14]. Most fruit drinks contain 10% or less fruit juice and a substantial amount of added
sugars.

Approximately one-third of young children consumed soft drinks in all three NHANES
analyses. These results are consistent with some previous from CSFII 1994–1996 [14], but lower than others including studies of NHANES 1999–2002 (39% 2–5 year olds)
[20] and CSFII 1994–1995 (51%) [29]. As children age from 1 year to 5 years, a greater percentage of the population consumed
soft drinks. In NHANES 2001–2006, 19% of 1 year olds consumed soft drinks, which increased
to 45% by age 5 years. The mean amount of soft drinks marginally increased from 7
fl oz/day in NHANES 1976–1980 to 7.8 fl oz/day in NHANES 1988–1994 and 7.9 fl oz/day
in NHANES 2001–2006. These findings are similar to data from CSFII 1994–1996 [14] but appreciably higher than 2.9 fl oz/day indicated by Rampersaud et al. [29] for CSFII 1994–1996, 1998. Carbonated beverages were negatively associated with meeting
the recommended levels of vitamin A, vitamin C, and calcium [14].

The cumulative consumption of beverages with added sugar has been inversely linked
to overall diet quality and meeting the adequacy of several nutrients [15]. In our analysis of the most recent NHANES, an additional 85 empty calories or 5%
of total daily intake was consumed as soft drinks. The decline in milk consumption
and the steady intake of nutrient poor beverages such as fruit drinks and soft drinks
in our analysis is corroborated by others. Carbonated beverages and added sugar juice
drinks were inversely associated with milk intakes in children 1–5 years of age in
the Iowa Fluoride Study [15]. Harnack et al. [30] reported in their analysis of CSFII 1994 that high soft drink consumption appears
to displace milk and fruit juice in the diets of preschool aged children. For example,
those that consumed 9 fl oz or more soft drinks per day were 3.8 times more likely
to consume less than 8 oz of milk per day compared to those that did not drink any
soft drinks. Although the issue of displacement of milk by other beverages cannot
be specifically addressed in cross-sectional data, evidence from longitudinal studies
validates this phenomenon. Fiorito and colleagues [31] followed non-Hispanic white girls from age 5–15 years starting in 1996 and observed
that early differences in carbonated beverage intake were predictive of later carbonated
beverage and milk intake as well as selected nutrients. Girls who consumed carbonated
beverages at age 5 years had higher intakes of carbonated beverages, lower milk intake,
higher intake of added sugars, lower protein, fiber, vitamin D, calcium, magnesium,
phosphorous, and potassium for the 10 years of follow-up. Another study of non-Hispanic
white girls who were followed from age 5–9 years observed that girls who consumed
adequate amounts of calcium consumed on average twice as much milk, had smaller decreases
in milk intake, and consumed 18% less sweetened beverages [32].

The link between beverage consumption, energy intake and body weight have been evaluated
in this young population, and is a significant concern because obesity tends to track
over time [33]. High intake of sweetened beverages is linked to increased energy intake, weight
gain and adiposity in children. Regular consumption of sweetened beverages between
meals by children 2.5–4.5 years more than doubled the odds of being overweight at
4.5 years [12]. In a longitudinal study of girls, sweetened beverage consumption (sodas, sport drinks,
fruit drinks, and sweetened coffee or tea) at age 5, but not milk or 100% juice, predicted
adiposity in childhood and adolescence [19]. Higher intake of sweetened beverages at 5 years was correlated with a higher weight,
percent of body fat, and waist circumference from 5–15 years of age [19]. Sweetened beverages in both of these longitudinal studies did not include flavored
milk but included sugar-sweetened or artificially sweetened fruit drinks and carbonated
beverages. Excessive fruit juice consumption in preschool children has been associated
with obesity in some [34] but not all studies [11,35]. Wiley [36] found milk intake was positively associated with BMI among children aged 2–4 years
in an analysis of NHANES 1999–2004 data while a cross-sectional analysis of NHANES
1999–2002 data of 2–5 year olds revealed that energy intakes of flavored milk drinkers
were higher than those that consumed plain milk or non milk drinkers, but BMI indices
did not differ among the three groups [27]. Huh et al. [37] reported in their study that milk intake at age 2 years, whether full or reduced-fat,
was not linked to the risk of overweight at age 3 years.

Our analysis was limited by the use of cross-sectional data and associated analytical
data across three time periods. But in the case of nationally, representative dietary
data, NHANES data is the only source currently available. Given the cross-sectional
approach of NHANES causality cannot be determined. Also the data was based on a single
24-hour dietary recall which may not be a fair representation of an individual’s usual
intake. The 24-hour dietary recall has been shown to be prone to both under- an over-reporting.
Nevertheless, this method has been shown to be valid in estimating the mean intake
of a population [38,39].

In summary, the number of young children consuming milk has significantly declined
while those consuming fruit juice has increased dramatically in the last decade compared
to the previous two decades. The proportion of children that consume fruit drinks
and soft drinks has remained high and relatively stable across the three decade time
period. Milk is the main source of calcium in the diets of these children, which has
been declining alongside increased reduced-fat milk consumption. Milk is also a major
source of magnesium and potassium, short-fall nutrients identified by the 2005 and
2010 Dietary Guidelines for Americans. The amount of milk that is consumed in this
age group is less than recommended, particularly among 4 and 5 year olds, where fruit
juice consumption is significantly higher than recommended. Fruit drinks are a significant
source of calories. A greater number of children consume soft drinks as they age from
1–5 years. Since dietary patterns established as young children are carried throughout
childhood and adolescence, and a link between non-milk sweetened beverages and obesity
has been increasingly demonstrated, it is prudent that parents, educators and child
caretakers replace some of the nutrient poor beverages young children are currently
consuming with low-fat and fat-free milk.

Competing interests

VLF as Senior Vice President of Nutrition Impact, LLC, performs consulting and database
analyses for various food and beverage companies and related entities. EEQ is an employee
of Dairy Research Institute/National Dairy Council.

Authors’ contributions

VLF designed the study, was primarily responsible for the data analysis, and provided
critical input into the manuscript; EEQ helped with data analysis and drafted the
manuscript. All authors read and approved the final manuscript.

Sources of support

Dairy Research Institute administered by the National Dairy Council

References

Birch L, Savage JS, Ventura A: Influences on the development of children’s eating behaviors: from infancy to adolescence.

Murphy MM, Douglass JS, Johnson RK, Spence LA: Drinking flavored or plain milk is positively associated with nutrient intake and
is not associated with adverse effects on weight status in US children and adolescents.